Exceptionally High Creatine Kinase (CK) Levels in Multicausal and Complicated Rhabdomyolysis: A Case Report

Cocaine-Induced Kidney, Liver, Lung, and Muscle Injury (C-KLM), Presenting With Foot Drop: A Case Report

Cocaine-associated organ injury is a well-known phenomenon that may lead to multi-organ failure. Cocaine-induced kidney, liver, lung, and muscle (C-KLM) involvement is an entity with alarmingly high creatinine phosphokinase (CPK) levels exceeding 100,000 U/L. This may have fatal outcomes. Rhabdomyolysis is one of the many mechanisms of kidney injury induced by cocaine intoxication. Sympathomimetic effects of cocaine contribute to muscle Injury in addition to vasoconstriction resulting in muscle ischemia, as well as liver ischemia (shock liver). Furthermore, increased muscular activity from hyperpyrexia, seizures, and agitation due to cocaine use disorder may contribute to muscle breakdown and worsening nephrotoxicity.  The authors detail a case of a 34-year-old male intravenous drug user who presented with an inability to bear weight or move his left lower extremity due to pain, associated with severe edema of his lower extremities of acute onset. He was subsequently noted with foot drop, oliguria, and high blood pressure following cocaine intoxication. The patient began crashing rather quickly and the intensive care unit was recommended. Labs were noted with overwhelming CPK levels over 100,000 U/L and rising for which urgent hemodialysis was initiated. We detail a catastrophic cocaine-induced multi-organ failure with a positive outcome following a multidisciplinary approach.

A Case of Daptomycin-Induced Rhabdomyolysis: A Life and Limb Threatening Complication

Surgical site infections (SSIs) contribute to patient morbidity and health expenditure. An increasing elderly population, the expanding use of implants in surgical procedures, drug-resistant microorganisms, and patient-related comorbidities all contribute to SSIs. Daptomycin is an antibiotic known to cause rhabdomyolysis, a life-threatening complication that may lead to acute compartment syndrome (ACS). We present a case of a patient treated with daptomycin for a penile-implant infection complicated by rhabdomyolysis and ACS of his bilateral forearms. He underwent emergent fasciotomies and retained function in his upper extremities long-term. It is vital that physicians closely monitor patients treated with IV-daptomycin therapy and educate patients on alarm symptoms to allow for prompt recognition of life and limb-saving treatments. Orthopedic surgeons should always have a high index of suspicion for ACS and should be aware of the relationship between rhabdomyolysis and ACS.

Serum creatine kinase levels are not associated with an increased need for continuous renal replacement therapy in patients with acute kidney injury following rhabdomyolysis

Severe rhabdomyolysis can lead to acute kidney injury (AKI). Previous studies have reported a benefit from continuous renal replacement therapy (CRRT) for rhabdomyolysis-associated AKI. Here, we investigated the potential for serum creatine kinase (CK) levels to be used as a marker for CRRT termination in patients with AKI following rhabdomyolysis. We compared different CK levels in patients after CRRT termination and observed their clinical outcomes. We retrospectively collected 86 cases with confirmed rhabdomyolysis-associated AKI, who were receiving CRRT in Tongji Hospital. Patients’ renal functions were assessed within 24 h of intermission, patients with urine output ≥ 1,000 mL and serum creatinine ≤ 265 umol/L were considered for CRRT termination. After termination, 33 patients with a CK > 5,000 U/L were included in an experimental group, and 53 patients with a CK < 5,000 U/L were included in a control group. Clinical outcomes were compared between the two groups. Higher CK levels, as well as worse renal functions, predicted the necessity of CRRT. After CRRT termination, the in-hospital mortality (p = 0.389) and Multiple Organ Dysfunction Syndrome (MODS) incidence (p = 0.064) were similar between the two groups, while the experimental group showed a significantly shorter in-hospital length of stay (p = 0.026) and Intensive Care Unit (ICU) length of stay (p = 0.038). CRRT termination may be independent of CK levels for patients with rhabdomyolysis-associated AKI, and this is contingent on their renal functions having recovered to an appropriate level.

Extraordinary Creatine Phosphokinase Levels in Coxsackie B Necrotizing Myopathy Complicated by Rhabdomyolysis

Coxsackie B infections can have varying clinical presentations. Necrotizing myopathy and rhabdomyolysis with remarkably high creatine phosphokinase levels is a rare complication associated with high morbidity and mortality. A 28-year-old male presented with complaints of weakness, body aches, and decreased urine output. Initial lab work showed a creatine phosphokinase level estimated at 5,366,100 U/l. Initial Coxsackie B4 titers were at 1:160. Muscle biopsy of the right calf revealed necrotizing myopathy consistent with viral myopathy. This case highlights Coxsackie B4 as a potential pathogen that can cause extensive muscle necrosis producing extreme creatine phosphokinase levels leading to rhabdomyolysis. Taking a comprehensive history is essential to identify viral prodromal symptoms to guide broader serological testing for uncommon viral species.

Extreme Elevation of Creatine Kinase in a Young Male Patient With Recurrent Rhabdomyolysis

Rhabdomyolysis is a common cause of admission to the intensive care unit. However, recurrent rhabdomyolysis remains a rare encounter for intensivists and presents a challenge in terms of identifying its etiology. Considerations of metabolic myopathies as a culprit remain underexplored. We present a case of a patient with recurrent rhabdomyolysis with extreme elevation of creatine kinase.

Psychosis-Induced Exertional Rhabdomyolysis without Acute Kidney Injury or Myoglobinuria

Patient: Male, 21-year-old

Final Diagnosis: Rhabdomyolysis

Symptoms: Myalgia • psychosis

Medication: —

Clinical Procedure: Intravenous hydration

Specialty: General and Internal Medicine

Bioinformatic HLA Studies in the Context of SARS-CoV-2 Pandemic and Review on Association of HLA Alleles with Preexisting Medical Conditions

After the announcement of a new coronavirus in China in December 2019, which was then called SARS-CoV-2, this virus changed to a global concern and it was then declared as a pandemic by WHO. Human leukocyte antigen (HLA) alleles, which are one of the most polymorphic genes, play a pivotal role in both resistance and vulnerability of the body against viruses and other infections as well as chronic diseases. The association between HLA alleles and preexisting medical conditions such as cardiovascular diseases and diabetes mellitus is reported in various studies. In this review, we focused on the bioinformatic HLA studies to summarize the HLA alleles which responded to SARS-CoV-2 peptides and have been used to design vaccines. We also reviewed HLA alleles that are associated with comorbidities and might be related to the high mortality rate among COVID-19 patients. Since both genes and patients' medical conditions play a key role in both severity of the disease and the mortality rate in COVID-19 patients, a better understanding of the connection between HLA alleles and SARS-CoV-2 can provide a wider perspective on the behavior of the virus. Such understanding can help scientists, especially in terms of protecting healthcare workers and designing effective vaccines.

Effects of microplastic exposure on the blood biochemical parameters in the pond turtle (Emys orbicularis)

The accumulation of microplastics (MPs) is a growing problem in aquatic ecosystems. Despite increased research on MPs in the last decade, their potential threat to freshwater ecosystems remains an open question. In the present study, the negative impacts of MPs were investigated on blood biochemical parameters in the European pond turtle (Emys orbicularis). Pond turtles were distributed into three experimental groups (n = 9 for each group) and were fed diets containing 250, 500, and 1000 mg MPs (PE100 polyethylene) per kg of food for 30 days, and a control group fed with a standard uncontaminated diet. The results indicated that exposure to 500 and 1000 mg kg^-1 MPs caused a significant increase in the activities of alanine and aspartate aminotransferases, and in the levels of cholesterol, glucose, creatinine, urea, and calcium (Ca⁺²) compared with the control group. On the contrary, the activity of gamma-glutamyl transferase and the levels of total protein, albumin, total immunoglobulins, and phosphorus were significantly reduced in E. orbicularis exposed to 500 and 1000 mg kg^-1 MPs when compared with the controls. In all the MP-exposed groups, the activity of lactate dehydrogenase and globulin and magnesium (Mg⁺²) levels were significantly reduced; while creatine phosphokinase and alkaline phosphatase activities were increased with respect to the control turtles. A significant decrease in triglyceride levels was reported in E. orbicularis exposed to 1000 mg kg^-1 MPs. MPs intake induced notable alterations in blood biochemical parameters of E. orbicularis. These results suggest that changes in the blood biochemical parameters could be an appropriate bio-indicator to evidence the existence of tissue damage in E. orbicularis.

Dermatomyositis-Induced Rhabdomyolysis With Features of Necrotizing Myopathy and Acute Inflammatory Demyelinating Polyneuropathy in an Epstein-Barr Virus Infected Patient

Dermatomyositis (DM) is an autoimmune inflammatory myopathy characterized by features of a typical rash, proximal muscle weakness, and evidence of muscle inflammation. Acute inflammatory demyelinating polyneuropathy (AIDP) is an autoimmune peripheral nerve disease characterized by myelin damage and progressive areflexic weakness and sensory changes. AIDP can be precipitated by viral infections such as Epstein-Barr virus (EBV). We present a case of DM with rhabdomyolysis and necrotizing features, along with AIDP in the setting of EBV viremia. DM and AIDP rarely coincide together. The patient was treated with a combination therapy of methylprednisolone, azathioprine, and intravenous immunoglobulins (IVIGs), which led to significant improvement in his symptoms.

Bioaccumulation of heavy metals and their toxicity assessment in Mystus species

This study was conducted on two native fish species namely Mystus vittatus and Mystus tengara inhabiting challenging environment of Yamuna River. The heavy metals concentrations in the river water were found to be as follows: Fe > Mn > Zn > Cu > Ni > Cr > Cd, all above the Bureau of Indian Standards (BIS) and World Health Organization (WHO) guidelines. The high metal pollution index in gill, liver, and kidney of M. vittatus was recorded compared to M. tengara. The pathology caused by the accumulation of heavy metals resulted significantly (p < 0.05) higher enzyme activities of alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and creatinine kinase (CK) in M. tengara as compared to M. vittatus. However, albumin: globulin ratio was found to be below 0.8 in both fishes. Higher total leukocyte (TLC) (48.5 × 10³/mm³), lymphocytes (40%), respiratory burst activity (1.9), and nitric oxide synthase (NOS) activity (13.11 U/L) in M. vittatus reflect high immune response. In addition, chromosomal breakage study showed significantly (p < 0.05) low micronuclei frequency, lobed nuclei, and kidney-shaped nuclei (KSN) in M. vittatus. These results indicate that under the same challenging conditions M. vittatus have more capability of resistance and its continuous survival points towards its suitability to serve as a bioindicator than M. tengara.

Myositis and acute kidney injury in bacterial atypical pneumonia: Systematic literature review

BACKGROUND

Bacterial community-acquired atypical pneumonia is sometimes complicated by a myositis or by a renal parenchymal disease. Available reviews do not mention the concurrent occurrence of both myositis and acute kidney injury.

METHODS

In order to characterize the link between bacterial community-acquired atypical pneumonia and both myositis and a renal parenchymal disease, we reviewed the literature (United States National Library of Medicine and Excerpta Medica databases).

RESULTS

We identified 42 previously healthy subjects (35 males and 7 females aged from 2 to 76, median 42 years) with a bacterial atypical pneumonia associated both with myositis (muscle pain and creatine kinase ≥5 times the upper limit of normal) and acute kidney injury (increase in creatinine to ≥1.5 times baseline or increase by ≥27 μmol/L above the upper limit of normal). Thirty-six cases were caused by Legionella species (N = 27) and by Mycoplasma pneumoniae (N = 9). Further germs accounted for the remaining 6 cases. The vast majority of cases (N = 36) presented a diffuse myalgia. Only a minority of cases (N = 3) were affected by a calf myositis. The diagnosis of rhabdomyolysis-associated kidney injury was retained in 37 and that of acute interstitial nephritis in the remaining 5 cases.

CONCLUSION

Bacterial atypical pneumonia may occasionally induce myositis and secondary kidney damage.

Heavy metal pollution and risk assessment by the battery of toxicity tests

The current study was carried out on dominant fish Oreochromis niloticus and water collected from the polluted Yamuna River, Agra, India. The heavy metals in water, recorded as follows: Fe > Mn > Zn > Cu > Ni > Cr > Cd and all were found to be above the prescribed limits. According to metal pollution index, exposed muscle (49.86), kidney (47.68) and liver (45.26) have been recorded to have higher bioaccumulation. The blood biochemical analysis of exposed O. niloticus indicated significant increase in activities of aspartate aminotransferase (+ 343.5%), alkaline phosphatase (+ 673.6%), alanine aminotransferase (+ 309.1%), and creatinine (+ 494.3%) over the reference. However, a significant decrease in albumin (A): globulins (G) ratio (− 87.86%) was observed. Similarly, the exposed fish also showed significant increase in total leucocyte count (+ 121%), differential leucocyte count, respiratory burst (+ 1175%), and nitric oxide synthase (+ 420%). The histological examination of liver and kidney showed tissue injury. Moreover, micronuclei (0.95%), kidney shaped nuclei (1.2%), and lobed nuclei (0.6%) along with DNA damage in the form of mean tail length in the liver (20.7 µm) and kidney (16.5 µm) was observed in the exposed O. niloticus. Potential health risk assessments based on estimated daily intake, target hazard quotient, hazard index, and target cancer risk indicated health risks associated with the consumption of these contaminated fishes. In conclusion, the present study showed that exposure to heavy metals contaminated water can alter immunological response; induce histopathological alterations and DNA damage in the studied fish. The consumption of this contaminated water or fish could have serious impact on human health.

Comparative studies of the expression of creatine kinase isoforms under immune stress in Pelodiscus sinensis

The expression and localization of different isoforms of creatine kinase in Pelodiscus sinensis (PSCK) were studied to reveal the role of PSCK isozymes (PSCK-B, PSCK-M, PSCK-S) under bacterial infection-induced immunologic stress. The computational molecular dynamics simulations predicted that PSCK-S would mostly possess a kinase function in a structural aspect when compared to PSCK-B and PSCK-M. The assay of biochemical parameters such as total superoxide dismutase (T-SOD), lactate dehydrogenase (LDH), malondialdehyde (MDA), catalase (CAT), and the content of ATP were measured along with total PSCK activity in different tissue samples under bacterial infection. The expression detections of PSCK isozymes in vitro and in vivo were overall well-matched where PSCK isozymes were expressed differently in P. sinensis tissues. The results showed that PSCK-B mostly contributes to the spleen, followed by the liver and myocardium; PSCK-M mostly contributes to the liver, followed by the myocardium and skeletal muscle, while PSCK-S contributes to the spleen and is uniquely expressed in skeletal muscle. Our study suggests that the various alterations of PSCK isozymes in tissues of P. sinensis are prone to defense the bacterial infection and blocking energetic imbalance before severe pathogenesis turned on in P. sinensis.

Extreme Rhabdomyolysis, Acute Renal Failure, and Protracted Ileus in a Case of Legionella Pneumonia

A 53-year-old man developed a Legionella pneumophila pneumonia complicated by rhabdomyolysis, acute kidney injury, and protracted ileus. Risk factors were smoking and chronic alcoholism, but the patient had no history of previous abdominal surgery. Hemodialysis was required for a period of 5 weeks with a full renal recovery. Pneumonia required respiratory support but for a limited period of 6 days. The protracted course of the ileus led to explorative laparotomy despite negative computed tomography findings. No cause of mechanical obstruction was found at surgery and common etiologies of intestinal obstruction were excluded. Parenteral nutrition was needed for a total of 4 weeks, before recovery of intestinal motility. This case illustrates the apparent discrepancy between the pulmonary symptoms and the extrapulmonary manifestations that could be seen as a consequence of an exaggerated immune response.

Massive Rhabdomyolysis; A Rare Cause of Hepatocellular Dysfunction

BACKGROUND Rhabdomyolysis syndrome is a rare surgical complication. It is infrequently reported in prolonged operations under lateral decubitus position. This syndrome mainly impacts kidney function and electrolytes levels; liver is another organ that is uncommonly affected. CASE REPORT A 54-year-old male underwent a partial hepatectomy in the supine position, the procedure lasted three hours. After five days of uneventful recovery from surgery, he was readmitted to the hospital with rhabdomyolysis syndrome involving his lower limbs. No predisposing factors other than surgery could be identified. Based on blood tests, the only affected organ was the liver. Upon aggressive hydration, the creatinine kinase, hepatic enzymes, bilirubin levels, and prothrombin time were normalized. The patient regained normal physical strength over the next few weeks. CONCLUSIONS Liver dysfunction secondary to rhabdomyolysis is rare but should be considered when other causes are excluded. Prothrombin time, bilirubin levels and albumin levels may help to identify concomitant liver damage. Rhabdomyolysis is rarely reported in liver resection surgeries.